HomeMy Public PortalAbout5505 RYLAND AVE_Sewer__ '6A64o62 APPLICATION FOR PER IT e'
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FNEAREST
NG
JOHN A. LAMBIE. COUNTY ENGINEER ss - J � f
COLEMAN W. JENKINS. SUPT. OF BUILDING ;
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FOR APPLICANT TO FILL IN 5T. ,
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DESCRIPTION LOT NO. 4 _ _ OWNER (" ,A
MAIL i
BLOCKTRACT AADDRESS
NO. OF SLOGS. -�
SIZE OF LOT NOW ON LOT - CITY TEL. NO.
USE OF
BUILD G5 DISTRICT NO, GROUP MAF PROCESSED BY
BK PG
CONTRACTOR �y Z j x ,,V.- ice: -',-- 0 .✓ �J _ C, ` ' .-
s.-,L_ _-
ADDRESS _ CONNECTION DATA
CITY I _ TEL. NO. -' STATION DEPTH
�3
STATE l Y - LIC MANHOLE REFERENCE UPPER
LICENSE NO.
CLASS ��, LOWER
No .DESCRIPTION OF WORK FEE TY_PEOF _--
CONNECTION LENGTH FROM
HOU
_E _SSEWER CONNECTING TO I Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER $5.00 - -
SEPTIC TANK,SEEPAGE PIT OR P.C.NO.
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO. 30B NOm f,f'
-__
NOUSE'S
EWER CONNECTING TO TRUNK PERMIT NO. - ROAD PERMIT NO. ix
PRIVATE DISPOSAL SYSTEM $3.00 0
i CONNECT ADDITIONAL BLDG OR I AFFIDAVIT WAIVER EASEMENT RECORD.INSTP..NO. DATE
WORK TO HOIJSE,SEWER _ - $3:00 -�� �
I OVERFLOW SEEPAGE PIT.DRAINFIELD - 7
EXTN..CESSPOOL.DRYWELL.MANH OLE @ $5.00
t ',REPAIR HOUSE HWY.OR ST.WIDENING z
EWER SYSTEM $3-00-4-_ _ STATE ENCROACHMENT _ ,(
- PERMIT NO. Cz-ce
INDUSTRIAL
WASTE APPROVAL
(OWNER'S PERMIT z oo — CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE -----
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE -
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING -- "-------
TO THE PUBLIC SEWER. APPROVALS {- DATE INSPECTOR'S SIGNATURE
SIGNED THIS.. DAY OF--19-
OWNER
F19,_OWNER OR NEW HOUSE SEWER
OWNERS AGENT_ CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS____-___.
- - - --' SEPT'1C TANK,SEEP,PIT{S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AN STATE. THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY _ ___.-___.._-____-_..- -------- -.-
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING CESS POO DRYW ELL ❑
PLUMBING AND SEWERS. _
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAI SEWER OR I t"
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWA SALSYSTEM tt
�y
CAL PORN IA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE ABOVE DESCRIBED RESIDENTIAL PROPERTY.. ABANDON HOUSE SEWER
SIGNATURE r BACKFILL SEPTIC TANKS ❑
OF PERMITTEE _ -- ---- SEEP.PIT(S) ❑ CESSPOOLS ❑I
i
VALIDATION--- JACK R. ALLEN
SUPERVISING MECHANICAL ENGINEER
CK. M.O. ( CASH r'
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